Definition: -
Physical Examination is a head to toe
review of body systems that offer objective information about the client.
OR
It is a process to gather
comprehensive, pertinent assessment data by examining all the body parts from
head to toe to assess the clients physiological functioning.
Purposes: -
1.
To
ascertain the clients level of health & physiological function.
2.
To
identify factors placing the client at risk.
3.
To
confirm alterations disease as inability to perform the activities of daily
living.
4.
To
identify the need for additional testing or examination.
5.
Gather
baseline data about the client’s health status.
6.
Supplement,
confirm or refuel data obtained in the history.
7.
To
identify & confirm Nursing diagnosis.
8.
Make
clinical judgments about a client changing health status management.
9.
To
evaluate the outcomes of treatment and therapy.
Preparation for Examination:-
1. Patient : -
·
The
patient should be explained well about the procedure.
·
The
patient’s doubts should be classified.
2.
Nurse : -
·
Nurse
should be confident, calm, organized & competent at the bedside.
·
Nurse
must demonstrate respect for the client’s apprehension.
·
Nurse
should review the agencies assessment form before meeting the client.
3.
Environment : -
·
Provide
privacy to the patient.
·
The
room should be quiet, warm, without draft & well it.
·
Avoid
any kind of interruptions during the procedure.
4.
Equipments : -
The instruments used in physical
examination should be
-
Easily
accessible.
-
Clean
or sterile.
-
In
proper working order
-
Organized
for their sequence of use.
-
The
equipment that will touch the patient should be warmed before use by examiner’s
hand or warm water.
A tray containing: -
1.
Aromatic substances like coffee, juices etc.
2.
Cotton balls in a bowl.
3.
Safety pin : - Disposable sharp object to
assess pain, Sensory system
4.
Tape
Measure: - Calibrated in cm to measure circumference.
5.
Tongue
depressor: - Wooden tongue blade to inspect oral cavity & stimulate
gag reflex to assess IX & X
(glossopharyngeal & vagus) cranial nerves.
6.
Tuning
fork: - Metal fork that vibrates when taped & is used to perform Rinne’s
test to assess VIII (acoustic) cranial nerve.
7.
Lubricant:
- Facilities insertion of instrument into body cavities.
8.
Drape:
- covers exposed body parts.
9.
Clean
gloves.
10. Laryngeal mirror – metal instrument
with mirror to inspect pharynx & oral
cavity.
11. Ophthalmoscope – lighted instrument
attached to a battery tube to visualize the eye’s interior.
12. Otoscope or Ear speculum: - Special
ear speculum attached to an ophthalmoscope to visualize eternal & middle
ear (eardrum).
13. Penlight : - Flashlight to test
papillary reaction to light & to assess III, IV & VI cranial nerves
(coulometer , tracheal, & abducent)
14. Percussion Hammer – Instrument with
rubber head to test reflexes.
15. T.P.R. tray – To check Vital signs.
16. Sphygmomanometer – To check blood
pressure.
17. Stethoscope – To do auscultation and
to check B.P.
Positioning for
procedures: -
1)
Sitting
– for head, neck, back, throat, lungs, heart, breasts, axillae and upper
extremities examination and to check vital signs.
2)
Supine
– for head, neck, anterior thorax, and abdominal examination also to check
vital signs.
3)
Lithotomy
– For examination of female genitalia & genital tract
4)
Sim’s
lateral – for rectum & vagina examination
5)
Prone
– for musculo-skeletal system assessment.
6)
Knee-chest
position - Rectum and vaginal assessment.
Techniques of physical Examination:
-
There
are four techniques of physical examinations.
1.
Inspection.
2.
Palpation.
3.
Percussion.
4.
Auscultation.
1.
Inspection: - Inspection is the process of
performing deliberate, purposeful observations in a systematic manner. Inspect
each area of the body for size, Colour, shape, position & symmetry. Noting
normal findings and any deviations from normal. The nurse uses her hearing
& smelling along with observations to gather data throughout the
assessment.
2.
Auscultation: - It is listening to internal body
sounds to assess normal sound and detect abnormal sounds. It is done by use of
stethoscope. Commonly assessed sound are Heart, Lungs, Abdominal and Vascular
system.
Techniques: -
· Hold the diaphragm of stethoscope
between index & middle finger firmly against the skin surface and use it to
hear high pitched sound such as heart sound, lungs sound and blood pressure.
· Place the bell lightly in contact
with skin to hear low pitched sound such as murmur (a soft whisper, mumble, low
sound) and bruit.
· Auscultate the sound for
characteristics
Ø Pitch (high/low),
Ø Intensity (soft/louder),
Ø Duration (long/medium/short)
Ø Quantity
(Grunting/blowing/whisting/bhowing/whisting/snaping)
Stethoscope – picture / figure
Parts of
stethoscope
The tubing should
not be longer than 12 – 15 “
3.
Percussion: - It is a technique to assess
tissue density by sound produced by tapping/ striking the skin, which determine
the location, size and density of underlying structure to assess
abnormalities.
Techniques: -
1)
Direct
percussion – Use one or two finger to percuss directly against a body surface
2)
Indirect
percussion – Place the distal phalanx ( Tip of Finger) of the middle finger of
your non dominant hand (Pleximeter) on
the clients skin over soft tissue
3)
Bend
the middle finger of your dominant hand ( Plexor) to create a hammer.
4)
Now
strike plexor on pleximeter sharply and quickly .
5)
Percussion
result in fine characteristics sound : -
S.N.
|
Sound
|
Characteristics
|
Areas
|
1.
|
Flatness
|
Soft, high pitched, short sound
|
Muscles
|
2
|
Dullness
|
Soft, moderate loud & pitched,
medium duration. Due to less dense tissue and fluid filled tissue
|
Liver & spleen
|
3
|
Resonance
|
Moderate to loud sound, Low
pitched, longer duration. Due to air filled tissue
|
Lungs
|
4
|
Hyper Resonance
|
Very loud, Low pitched, Longer duration.
Produced by Over inflated Air
filled lungs
|
Lungs
|
5
|
Tympany
|
Loud, high pitched, moderate
duration.
Drum like quality due to enclosed,
air containing structure.
|
Stomach and Bowel.
|
4.
Palpation: - Palpation is the assessment
technique that user the sense of touch. The hands & finger are sensitive
tools & can assess temperature, turgor, texture, moisture, vibrations &
shape. The dorsum (back) surfaces of the hand & fingers are used for gross
measure of temperature the palmer (front) surfaces of the finger & finger
pads are used to assess texture and to assess vibration of lungs
Assess position, consistency,
mobility, size, shape & skin turgor by lightly grasping tissue between the
thumb & index finger.
Techniques
of Palpation: -
1.
Light
palpation : - depress the underlying tissue approximately 1-2 cm (1/2”-3/4”)
2.
Deep
Palpation: - 4-5 cm (11/2-2”) to determine the size & condition of
underlying structure such as abdominal organs.
3. Bimanual palpation – place one hand lightly on the
client skin (sensing hand) and place the other hand (active hand) over the
sensing hand to apply pressure the saving hand remain sensitive to underlying
organ characteristics.
5.
Oflaction – It is the use of the sense of
smell to detect body order the sense of smell help defect abnormalities not
readily recognized by others.
For example - 1) smell of ammonia in
urine suggest UTI
2) Strong musty odor
from cast – a wound Infection
Sr.No.
|
Assessment Area
|
Client Position
|
Techniques
|
Equipment
|
What to observe
|
1
|
General
Survey
|
Standing Walking Sitting
|
Inspection Olfaction
|
Wt. Machine & Measurement
Tap Thermometer& Sphygmomanometer
|
a) General appearance and behavior: -
Apparent age, sex, race, health status, body build, posture, gait, any
deformities movement & ROM.
Skin – color and texture
Dress, hygiene and grooming, body
or breath odor
Mental status:- sign of distress,
affect, expression,
speech, memory, eye contact. Level
of
consciousness.
b) Height and Weight
c) Balance and co-ordination
d) Vital signs – T.P.R. , BP
|
2
|
Head and Neck
|
Sitting on edge of examination
table
|
Inspection
palpation
Palpation
Inspection
Inspection
Inspection
Inspection
Palpation
Inspection
Inspection
Inspection
Palpation
|
Tap measure
Stethoscope
Sneller
chart
Eye cover, pen
Penlight /
pen
Penlight /
pen
Ear specula Otoscope ( As per
hosp. policy if allowed to use by Nurses)
Tuning fork
( 512 Hz)
Penlight
Nasal specula
Penlight
Gloves,
Tongue blade,
Penlight
|
HEAD
1) Inspect
and palpate: skull size, shape, symmetry, tenderness, lesion and measure head
circumference if abnormal size
2) Inspect
hair & scalp: Color, integrity hair distribution and texture. Presence of
nits or lice hygiene.
3) Palpate
Temporal Arteries: thickening, Tenderness,
Auscultate for bruit if abnormality noted.
FACE
1) Inspect
symmetry , skin color , hair distribution
facial movement ( CN V &VII ) Clenched
jaws,
eye brows .
2) Palpate
TMJ ( Temporo-Mendibular joint) , Nodules, Temporal & Masseter muscle (
CN-V)
3) Test
facial sensation for light , touch , pressure and pain (CN V)
EYES
1) Visual
acuity ( CN- II)
2) Visual
fields (peripheral vision) by moving
one finger from center to peripheral(CN II)
3) EOM,
through six cardinal position of gaze ( CN III,IV,VI, VIII)
4) Convergence
(dilatation) and accommodation (constriction) of pupils (CN – III, IV, VI)
5) Corneal
light reflex ( CN – III, IV, VI)
6) Inspection
and Palpate external eye structures.
i. Eye
brow symmetry , alignment
ii. Eye
dash symmetry, hair distribution , direction of growth
iii. Eyelid
position , blinking
iv. Eyeball
symmetry
v. Conjunctiva
and sclera color, texture, lesion, foreign bodies.
vi. Cornea
textures, transparency (opaque in cataract), reflex.
vii. Pupil
– symmetry, Color, Size, reaction to light and accommodation ( CN – III,IV,VI)
EARS
1) Inspect
& palpate external ear structure :
a) Auricle
symmetry, placement, skin integrity, color, mobility tenderness.
b) Ear
canal – skin intensity , obstruction , discharge , foreign body
c) Tympanic
membrane symmetry, color, landmarks scars, fluid.
2) Hearing
Acuity – Response to normal conversation
-
Weber’s Test for sound lateralization
-
Rinne’s test for air & bone conduction
sound (CN VIII)
NOSE And SINUSES
1) Inspect
and palpate external nose alignment : skin color, lesion, tenderness,
discharge, nasal flaring
2) Inspect
vestibule - color, mucus membrane , septum alignment
3) Inspect
nasal canula for color, moisture,
4) Septum
for alignment, masses, perforation & alignment , exudates, inflammation
5) Palpate
and percuss frontal and maxillary sinuses for swelling & tenderness
6) Sense
of smell (CN – I) e.g. Coffee, spirit etc.
MOUTH AND PHARYNX
1) Inspect
& palpate – Lips & Oral mucosa for color, symmetry, texture ,
hydration, lesions,
2) Inspect
teeth & gums for hygiene, teeth alignment gum bleeding gum
3) Inspect
& palpate tongue & floor at Mouth for symmetry, color, tongue
position and size, texture, mobility, tension etc.
4) Tongue
mobility strength ( CN IX, XII)
5) Inspect
oral cavity for ulcer, tension, redness, texture.
6) Inspect
tonsils and pillars for color, size, shape, Inspect pharynx for color,
discharge, on post wall.
7) Test
gag reflux ( CN-IX, X) if swallowing impaired noted
8) Note
characteristics of Voice, ability to swallow (CN-IX, X)
9) Note
presence of breath odor.
10) Test
sense of taste (CN- VII, Ix) only if abnormality reported with sugar, salt, lemon
juice, bitter.
NECK
1) Inspect
neck muscle symmetry, ROM, strength (CN – XI)
2) Palpate
and inspect over partial and submondibular salivary glands for swelling,
tenderness.
3) Palpate
all cervical lymph nodes
4) Inspect
and palpate – Trachea and Thyroid gland for symmetry and alignment.
5) Inspect
jugular venous distension.
|
3.
|
Upper Extremities and Spine
|
Sitting on edge at examining
table
|
Inspect
Palpation
|
Reflex Hammer
|
UPPER EXTRIMETIES
1) Inspect
skin for lesion and palpate for turgor
2) Inspect
limb for alignment and symmetry
3) Inspect
fingernails and blench to test capillary refill, inspect clubbing
4) Palpate
peripheral pulses : brachial , radial, and ulnar and Pulse rate
5) Inspect
act palpate muscle group for size, symmetry & tone
6) Evaluate
& rate muscle strength.
7) Inspect
& palpate joints for swelling and tenderness.
8) Assess
ROM – Shoulder, elbow, wrist, and finger.
SPINE
1) Test
reflexes & rate response : biceps, triceps, brachioradialis
2) Assess
cerebellar function, finger to finger touch, hand supination & pronation.
|
4.
|
Posterior Thorax
|
Sitting on edge of table Nurse
stand behind client
|
Inspection
Palpation
percussion
Auscultation
percussion
|
Measurement Tap
Stethoscope
|
SPINE, RIBS, MUSCLES
1) Inspect
spine for alignment, palpate spine process for tenderness, inspect skin
integrity.
2) Inspect
rib cage for symmetry, shape , movement with respiration
3) Measure
antero-posterior and lateral diameter
4) Assess
thoracic expansion (respiratory excursion)
LUNGS
1) Observe
respiratory Pattern
2) Palpate
tactile fremitus & respiratory excursion
3) Percuss
posterior & lateral thorax
4) Measure
diaphragmatic excursion
5) Auscultate
breath sound – post & lateral thorax
6) Auscultate
voice , sound , If fremitus abnormal
KIDNEYS
Percuss our
cost – vertebral area for kidney tenderness
|
5
|
Anterior thorax
|
Sitting on edge of table Nurse
stand on right side of patient.
Sitting up & leaning forward
Sitting with arm at sides Houdson
hips, with arms raised over head
|
Inspection
Palpation percussion
Auscultation
Inspection
Palpation
Auscultation
Inspection
Palpation
|
Stethoscope
|
THORAX and LUNGS
1)
Inspect skin integrity
2)
Observe respiratory pattern
3)
Inspect rib cage for movement on respiration,
symmetry shape & use of
accessory muscles
4)
Palpate respiration excursion and tactile fremitus
5)
Percuss Anterior thorax
6)
Auscultate breath sound & voice fremitus.
HEART
1)
Inspect precardium for lift, heaves &
apical
pulse
2)
Palpate precardium for thrills, apical
impulse.
3)
Auscultate heart sound with client sitting up
than
learning & for ward
4)
Assess heart rate and rhythm
BREASTS AND AXILLAE
1) Inspect
breast in 3 position for size, shape, symmetry, skin lesion and contour
2) Inspect
areole and nipple for size, shape , color, symmetry and lesion
3) Inspect
axillae for rashes , masses, lesion, pigmentation
4) Palpate
axillae for lymph nodes
5) Palpate
breast areole & nipples with client supine and arm behind head for lumps
masses, consistency.
|
6
|
Abdomen
|
Supine position
|
Inspection Auscultation
Percussion palpation
Percussion
Percussion
palpation
palpation
|
Measurement Tap
Stethoscope
Stethoscope
|
ABDOMEN ( GENERAL)
1) Inspect
skin integrity and characteristic striae, various pattern hair distribution,
contour, symmetry, umbilicus, pulsation, peristalsis, rectus muscle and
abdomen girth.
2) Auscultate
all 4 quadrants for bowel sounds
3) Auscultate
major arteries / vessels for bruit abdomen aorta, renal iliac and femoral
arteries
4) Auscultate
over liver and spleen for peritoneal friction rub.
5) Percuss
all quadrants for mass and tenderness gastric bubble over bladder and spleen.
6) Lightly
palpate all quadrants for masses and tenderness follow by deep palpation.
7) Assess
for rebound tenseness over RLQ & LLQ.
LEVER
1) Percuss
liver size at RMCL (Right Mid clavicle
line) and MSL ( Mid sternum line ) and
mark border
2) Measure
liver span at RMCL and MSL
SPLEEN
1) Percuss
spleen size and if indicated Percuss for enlargement
AORTA
Palpate for
area of pulsation in epigastrium.
KIDNEY
1) Palpate
Right and Left kidneys
2) Blunt
percussion over costo-vartibral area (post.) for tenderness.
INGULNAC AREAS
1) Palpate
femoral Arteries and pulse rate
2) Palpate
inguinal lymph nodes : note characteristics.
|
7
|
Lower Extremities
|
Inspection
Palpation
Palpation
|
LOWER EXTREMITIES : -
1) Inspect
skin for lesions., hair distribution
2) Inspect
limb for alignment and symmetry
3) Inspect
toenails and blanch to test capillary refill
4) Palpate
peripheral pulses palatial posterior tibial dorsalis pedis.
5) Inspect
for edema and palpate for pitting if present
6) Palpate
for phlebitis (Inflammation of vain) Varicosities. (Increased diameter of
vein & decrease elasticity) measure circumferences of calve or thighs, if
phlebitis present.
7) Evaluate
muscle strength; hips, quadriceps, ankles, toes & feet.
8) Inspect
and palpate joint for swelling tenderness and crepitus.
9) Assess
ROM; hip, knees, ankles, feet and toes
10) Check
Deep tendon reflexes (DTRs) Test patellar, Achilles and planter cutaneous
reflex.
|
||
8
|
General
Neurolgical
|
Supine with eyes closed
Walking heel to toe
Hoping an each feet kne bends
|
Inspection
|
Cotton wisp
Sterile safty pin
Tuning fork
Key, Coin
|
SENALSORY FUNCTIONS
1)
Test perception of light touch over trunk,
face &
neck
2)
Test perception of pain vs. pressure over face
&
neck
3)
Test perception of vibration on toes &
fingers
4)
Test object identification both hard
5)
Test graspism of both hand
6)
Test temperature perception.
GROSS MOTOR AND BALANCE
1) Inspect
gait and balance white client walks on
heel to toe than on toes to heel
2) Observe balance while client stands on one
foot.
3) Observe
balance & Lower extremities strength while hops on the foot.
4) Observe
balance & strength while client perform shallow knee bands.
|
9
|
Male Genitalia and Anus
|
Standing
.
|
Inspection
|
Groves worn
throughout
|
MALE GANITALIA
1) Inspection
pubic hair and skin for hair distribution, rashes, lesion, or parasites.
2) Inspect
penis: Shaft, prepuce (foreskin) Glans, urethral meatus and observe for any
discharge.
3) Inspect
scrotum for size, symmetry, shape, swelling
ANUS
Inspect perineal skin for integrity,
color, rash,
lesion, fissures, ulcers, polyps,
inflammation ,
hemorrhoid
|
10
|
Female Genitalia and Anus
|
Dorsal recumbent
|
Inspection
|
Gloves worn throughout
|
FEMALE GENITALA
Inspect
external genitalia
-
Monspubis for pubic hair distribution &
texture
-
Perineal skin for color, lesion, irritation
-
Suspect labia majora & Minora for edema
(swelling) and symmetry
-
Inspect clitoris for color, and presence of
lesion.
-
Inspect urethral meatus for discharge,
inflammation
ANUS
Inspect perineal skin for integrity, color,
rashes, lesion, fissures, ulcer,
polyps & hemorrhoid.
|
11
|
REFLEXS
|
Sitting on edge of table
|
Inspection
|
Hammer
|
DEEP TENDON REFLEXES (DTRs)
Biceps –
i. Flex clients arm up to 45º at elbow with
palm
down.
ii.
Place your thumb in anticubital fossa at base
of
biceps tendon and your finger at
biceps muscle.
iii. Strike
triceps tendon with reflex hammer
Normal :
Flexion of arm at elbow
Triceps –
i.
Flex clients arm at the elbow, holding arm
across chest
ii.
Strike triceps tendon just above the elbow
Normal – Extension of Elbow.
Patellar –
i. Have
client sit with legs hanging freely over side of table/chair or have client lie supine
are support knee in a flexed 90 º position.
ii. Briskly tap patellar tendon just below
patella.
Normal – Extension of lower legs.
Achilles -
i. Have the client assume same position as for
patellar reflex.
ii. Slightly
dorsiflex client ankle by grasping toes in palm of your hand
iii. Strike
Achilles tendon just above heel at ankle malleolus.
Normal –
Planter flexion of foot.
|
ROLE OF NURSE AFTER THE EXAMINATION:-
CARE OF PATIENT –
1) After
completing the assessment, give the client time to dress.
2) The
hospitalized client may need help with hygiene and retuning to bed
3) When
the client is comfortable, it helps to share a summary of the assessment finding.
RECORDING & REPORTING:-
1) You
may record finding from the physical assessment during the examination or at
the end.
2) Record
the finding in available special form.
3) Review
all finding before assisting the client with discussing in above of a need to recheck
any information or gather additional date any information or gather additional data.
4) If
the findings have serious abnormality the client’s physician should be consulted.
CARE OF EQUIPMENT AND ENVIRONMENT:-
1) Support
staff may be delegated to clean the examination area.
2) Instrument
and equipment used should be washed and replaced after disinfection practice
3) If
examination done on bedside, clear away soiled items from bedside table and
change the bed linen if needed.
4) Be
sure to wash the hand after work.
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